Erythropoietin (EPO) in acute kidney injury
© Moore; licensee Springer. 2011
Received: 2 February 2011
Accepted: 21 March 2011
Published: 21 March 2011
Erythropoietin (EPO) is a 30.4 kDa glycoprotein produced by the kidney, and is mostly well-known for its physiological function in regulating red blood cell production in the bone marrow. Accumulating evidence, however, suggests that EPO has additional organ protective effects, which may be useful in the prevention or treatment of acute kidney injury. These protective mechanisms are multifactorial in nature and include inhibition of apoptotic cell death, stimulation of cellular regeneration, inhibition of deleterious pathways, and promotion of recovery.
In this article, we review the physiology of EPO, assess previous work that supports the role of EPO as a general tissue protective agent, and explain the mechanisms by which it may achieve this tissue protective effect. We then focus on experimental and clinical data that suggest that EPO has a kidney protective effect.
Erythropoietin (EPO) is a complex molecule, which regulates red blood cell production in the bone marrow. Recombinant human EPO (rHuEPO) is commercially available and is widely used for the treatment of anemia. In recent years, additional nonerythropoietic tissue/organ protective properties of EPO have become apparent, in particular for kidneys. In this article, we consider the evidence supporting EPO as a general tissue protective drug and discuss the potential mechanisms by which it may achieve this general effect. We then focus on the renal protective effects of EPO and the potential mechanisms through which it may confer this specific protection. Finally, we review the experimental studies and clinical trials of EPO in acute kidney injury (AKI)--discuss risks, lessons learned, and the need for further randomized studies in humans before any change in clinical practice is considered.
The physiological properties of EPO
The structure of the EPO molecule
EPO is a 30.4 kD glycoprotein and class I cytokine consisting of 165 amino acids . EPO has four acidic oligosaccharide side chains (3 N-linked and 1 O-linked) and contains up to 14 sialic acid residues. Its carbohydrate portion contributes 40% of its molecular weight . The N-linked polysaccharide side chains appear to be important for the biosynthesis and secretion of EPO, enhance its stability in blood, and limit hepatic clearance, thus facilitating the systemic transit of EPO from kidney to bone marrow .
Animal studies of EPO in AKI: ischemia-reperfusion models
IR: nephrectomy, 2 weeks recovery, then renal artery occlusion, ischemia 1 hr; reperfusion 28 days
EPO 500 U/kg i.v. before ischemia ± 90 min abdominal insufflation
↓microalbuminuria, ↑renal function recovery at 4 weeks; i.v. EPO better than mannitol for renal I-R injury protection
IR: transplanted with male bone marrow cells; reperfusion 2 or 4 weeks
EPO 5000 U 30 minutes before ischemia
↑GFR (4 weeks), →proteinuria/Hb (2 and 4 weeks), ↓tubulointerstitial changes
IR: occlusion of infrarenal abdominal aorta, ischemia 30 min, reperfusion 60 min vs. sham
EPO 1000 U/kg s.c. 5 min before ischemia
↓MDA levels, ↓SOD activity, ↓catalase ↓histopathological changes
IR: bilateral renal pedicle occlusion 1 day after last EPO injection, ischemia 45 min; reperfusion 24, 72 hr and 1 week
EPO 100 U/kg or 100 U/kg CEPO s.c. q. 2 days for 2 weeks vs. saline
CEPO: (no erythropoiesis) ↓apoptosis, ↓α-SMA expression, ↑tubular epithelial cell proliferation, ↓SCr. EPO: ↑Hb, ↓in apoptosis & α-SMA (not as marked as CEPO). CEPO more therapeutic than EPO.
IR: bilateral renal pedicle occlusion 1 day after last EPO injection, ischemia 60 min; reperfusion 24, 72 hr
EPO 100 U/kg s.c. every 2 days for 2 weeks (6 injections) vs. saline
↑HIF-1alpha-positive cells, ↑VEGF mRNA expression, ↓tubular hypoxia, ↓apoptotic and α-SMA-positive interstitial cells
IR: bilateral renal pedicle occlusion 1 day after last EPO dose, ischemia 45 min; reperfusion 24, 72 hr and 1 week
EPO or CEPO as above for 2 weeks
↑peritubular capillary endothelial cells. CEPO may protect kidneys from IR injury by promoting angiogenesis.
IR: unilateral nephrectomy; occlusion renal artery for 1 hr 1 week later, reperfusion 5 days
EPO 5000 U/kg IV at ischemia, then 1000 U/kg s.c. vs. no treatment
↓renal dysfunction, ↓cell death (histology at 5 days)
IR: bilateral renal pedicle occlusion, ischemia 45 min; reperfusion 48 hr
EPO 500 U/kg i.p. 20 min before ischemia
↓SCr, ↓urea, ↓histological injury, ↓tubular apoptosis
IR: bilateral renal pedicle occlusion, ischemia 45 min; reperfusion 1-7 days vs. sham/vehicle
EPO 5000 U/kg or DPO 25 μg/kg i.p. at time of ischemia or 6 hr after reperfusion
EPO & DPO at T0 and T6 -↓tubular apoptosis, ↓plasma creatinine/urea, ↑tubular regeneration (cell proliferation and mitosis)
IR: R nephrectomy, clamp L pedicle 45 min and reperfusion 45 min and 24 hr
EPO 1000 U/kg and genistein (tyrosine kinase inhibitor) 10 mg/kg 2 hr before ischemia
↓SCr, ↓urea, ↓TNF-α and IL-2 expression (proinflammatory mediators of I-R injury), ↓LDH (indicates lipid peroxidation), ↓histological injury; genistein reversed benefits of EPO
IR: uni/bilateral renal artery occlusion, 30 min ischemia, 24 or 48 hr reperfusion vs. sham/vehicle
EPO 5000 U/kg i.p. 30 min before ischemia
↓apoptosis, ↑regeneration, ↓casts, ↓plasma creatinine in vitro: ↓apoptosis, ↑mitosis/DNA synthesis
IR: bilateral renal artery occlusion, 30 min ischemia, 24 hr reperfusion vs. sham/vehicle
EPO 1000 U/kg/day s.c. 3 days before I-R, or EPO 1000 U/kg s.c. on reperfusion
↓plasma creatinine, ↓plasma AST, ↓histological injury, ↓kidney MPO and MDA levels
IR: bilateral renal pedicle occlusion, 45 min ischemia, 6 hr reperfusion vs. sham/saline
EPO 300 U/kg i.v. 30 min before ischemia, 5 or 3 min before reperfusion
↓tubular apoptosis, ↓tubular (NAG) and reperfusion (AST) injury, ↓histological injury, ↓SCr, better urine flow, ↑creatinine clearance
IR: bilateral renal artery occlusion, 40 min ischemia, 48 (1) or 96 (2) hrs reperfusion vs. sham/vehicle
1. EPO 200 U/kg i.p. at start. 6 and 24 hr after reperfusion; or 200 U/kg i.v. and 4, 10, 24, 48 hr after reperfusion
↓plasma creatinine, ↓polyuria, ↓FENa, ↑AQP/NHE/TSC expression (prevented down-regulation of AQPs and Na+ transporters)
IR: bilateral renal artery occlusion, 45 min ischemia, ≤72 hr reperfusion vs. sham/saline
EPO 3000 U/kg 24 hr pre I-R injury
↓SCr, ↓tubular necrosis, ↓tubular apoptosis, ↓tubular cell proliferation ↑bcl-2 protein, ↓caspase 3 activity, ↓JNK expression, dose-dependent
IR: R kidney occlusion, 30 or 45 min ischemia, simultaneous L nephrectomy, ≤ 96 hr reperfusion vs. sham/vehicle
EPO 500 or 3000 U/kg i.v. at ischemia then s.c. 24, 48 hr after
↑HCt, ↓ mortality (severe ischemia group), →SCr/weight
Each EPO molecule has two EPO receptor (EPOR) binding sites. There are two affinities of the EPOR for EPO in solution: one of high and one of low affinity (needs 1,000 times the concentration of EPO for activation) .
Physiological stimuli for EPO production/release
Approximately 90% of systemic EPO in adults is produced by peritubular interstitial fibroblasts in the renal cortex and outer medulla of the kidney. A feedback mechanism involving oxygen delivery to the tissues appears to regulate EPO production . Hypoxia-inducible factor (HIF) regulates transcription of the EPO gene in the kidney, which determines EPO synthesis. This process is dependent on local oxygen tension. HIF is quickly destroyed in well-oxygenated cells through ubiquitylation (tagging for degradation in the proteasome) by the von Hippel-Landau tumor suppressor protein (pVHL), but when oxygen delivery decreases, pVHL ceases its proteolysis of HIF, increasing the levels of HIF, which subsequently increases EPO production [10, 11].
Structure of EPO receptors
The EPO receptor (EPOR) is a 66 kD membrane glycoprotein typically consisting of 484 amino acids and 2 peptide chains; it belongs to a large cytokine and growth factor receptor family . Binding studies have demonstrated that the EPOR has different affinities for EPO and that EPOR isoforms with higher affinity for EPO may be responsible for the erythropoietic effects of EPO, whereas isoforms with a lower affinity for EPO binding may have nonerythropoietic effects, such as tissue protection .
Post-receptor (intracellular) effects of EPO
There are a number of common pathways through which EPO exerts its erythropoietic effects that also appear to confer tissue protection. EPO "classically" binds to two EPORs, which become joined as a homodimer and change. This activates JAK2, which is bound to the common beta subunit of the EPOR  and leads to phosphorylation of tyrosine residues of the EPOR, which activates a number of signaling pathways (Figure 1).
EPO classically signals through the "signal transducer and activator of transcription 5" (STAT-5) pathway. The STAT proteins are direct substrates of Janus kinases (JAKs), which results in tyrosine phosphorylation of the STATs as well as phosphorylation of the phosphatidylinositol 3-kinase (PI3K) and subsequent phosphorylation of Akt (Figure 1).
The phosphorylation of mitogen-activated protein kinases (MAPKs) appears to contribute to the cell protection EPO confers (Figure 2). Protein kinase C (PKC) also is involved in inhibition of apoptosis and cell survival. It regulates the EPO-induced erythroid proliferation and differentiation  and interferes with phosphorylation of the EPOR, making it a likely upstream modulator of the EPOR.
EPO may be involved in modulation of cellular calcium homeostasis by increasing calcium influx . Nuclear factor-kappaB (NF-kB), a mediator of inflammatory and cytokine response, is implicated in EPO signaling. The cytoprotection of EPO partly depends on Akt and subsequent NF-kB activation (Figures 1 and 2). NF-kB plays a role in the release of EPO during HIF-1 induction; Akt can increase NF-kB and HIF-1 activation with resultant increase in EPO expression .
Finally, induction of heat shock protein 70 (HSP70) by EPO is related to renal protection in ischemic kidneys . HSP70 prevents apoptosis by inhibiting movement of apoptosis inducing factor (AIF) to the nucleus  and by preventing Apaf-1/cytochrome C binding in the cytosol  (Figure 2).
Red blood cell effects of EPO
The principal physiological function of EPO is red blood cell production, which results from a tightly controlled proliferation and differentiation pathway . Early hematopoietic progenitor cells differentiate into burst-forming unit-erythroid cells (BFU-Es). Continuous stimulation with EPO triggers the differentiation of CFU-Es into erythroblasts, which lose their nuclei to form reticulocytes. After a few days, reticulocytes lose reticulin and become erythrocytes (red blood cells). Reticulocytes and erythrocytes stop expressing EPOR and cease being responsive to EPO .
EPO-binding to EPORs on erythroid progenitor cells leads to activation of the JAK2-STAT5 signaling pathway and phosphorylation of PI3K and Akt1  (Figure 1). Akt-mediated phosphorylation of Bad in the Bad-Bcl-xL complex releases the antiapoptotic protein Bcl-xL, which suppresses erythroid progenitor cell apoptosis . Akt also is involved in several pathways that promote cell survival and antiapoptotic effects through inhibition of FOXO3a, inactivation of GSK3β, induction of XIAP, inactivation of caspases, and prevention of cytochrome C release (Figure 2). These effects not only enhance the erythropoietic properties of EPO but appear to be important in the protection of other cell types and may contribute to the reported neuronal and renal protective effects .
The pleiotropic effects of EPO
The tissue protective or "pleiotropic" effects (from the Greek, πλείων - pleion, meaning "more," and τρέπειν - trepein meaning "turn or convert") of EPO beyond erythropoiesis have been shown in the kidney in many animal and some clinical studies.
Its tissue protective effects may be elicited through the EPOR homodimer via JAK2-STAT5 activation and inhibition of apoptosis or may be mediated by a second EPOR isoform heterodimer composed of an EPOR monomer and the cytokine receptor, common beta subunit (CD-131). For example, carbamylated EPO (CEPO) does not bind to the classical EPOR isoform and is devoid of hematopoietic activity; however, it can provide tissue protection in the kidney, supporting the existence of a heteroreceptor EPO isoform, which mediates tissue protection . It is clear that the relationship of EPO with its receptor is extremely complex. Therefore, further investigation is required to fully understand the EPOR heterodimer isoform, and the mechanisms and pathways involved in its tissue protective activity.
Animal and in vitro studies
Animal studies of EPO in nonischemic models of AKI
Brain death + Perfused kidney model
10 μg/kg EPO or CEPO IV, 4 hr brain death, then kidney reperfusion in perfused kidney model
EPO and CEPO: ↓expression of proinflammatory genes, ↓infiltration of polymorphonuclear cells in kidney, preserved vascular integrity. CEPO more effective than EPO. Kidney function fully restored with EPO and CEPO.
Aristolochic acid nephropathy
DPO 0.1 mcg/kg wkly from day of Aristolochic acid administration or on day 28
↑survival of tubular cells lead to ↓acute tubular injury, interstitial inflammation and interstitial fibrosis.
CIN: Ioversol 2.9 g/kg iodine + inhibition of prostaglandin and NO synthesis
EPO 10,000 U/kg or asialoEPO 80 ng/g i.v. 1 hr before Ioversol
↓renal dysfunction and histological injury, ↓apoptosis, ↓caspase3-activated apoptosis in renal porcine epithelial cells in vitro with ↑JAK2/STAT5 phosphorylation and HSP70 expression; ↑JAK2/STAT5 phosphorylation and HSP70 expression in rat kidneys in vivo.
in vitro /CIN: cisplatin 5.5 mg/kg i.v.
EPO 5,000 U/kg i.v. OR equivalent peptide mass of inactive EPO OR DPO 25 μg/kg before cisplatin OR saline
EPO ↑HCt, ↓SCr; DPO also ↑HCt, ↓SCr. Clearance studies: GFR and renal blood flow confirmed DPO renal protection. ↓tubular apoptosis and necrosis with DPO. DPO 48 hr after cisplatin was renoprotective.
CIN: i.p. cisplatin injection (10 mg/kg/day) for 2 days vs. placebo. Follow-up 6 days.
EPO 1,000 U/kg i.p. daily ≤ 3 days before cisplatin vs. vehicle
↓urea, ↓casts, ↑marrow stem cell (MSC) numbers
Endotoxemia: 2.5 mg/kg endotoxin i.p. (lipopolysaccharide); follow-up 16 hrs later
EPO 4000 U/kg 30 min before endotoxin vs. vehicle
↑GFR (inulin clearance), →MAP, →Renal bld flow, ↑CRP, →serum NO, EPO reversed the endotoxin effect on renal SOD activity (SOD ↓ in control group).
CIN: (iothalamate), following indomethacin and Nω nitro-L-arginine methyl ester
EPO 3000 U/kg and 600 U/kg i.v. 24 and 2 hr pre-CIN induction vs. saline
Creatinine clearance preserved
Chronic kidney disease
DPO s.c. 0.4 μg/kg/wk into 5/6 remnant kidney rats after renal mass reduction
↑microvascular density, ↑endothelial proliferation, preserved renal function (↓SCr), ↓scarring, ↑VEGF expression
Hemorrhagic shock and endotoxic shock
EPO 300 U/kg i.v. before resuscitation
↓renal dysfunction in hemorrhagic but not endotoxic shock
CIN: cisplatin toxicity - i.p. cisplatin injection 6 mg/kg vs. placebo
EPO 100 U/kg i.p. before cisplatin, then daily for 9 days vs. placebo
↑renal blood flow/GFR at 9 days, ↑ tubular regeneration, ↑tubular cell proliferation, ↑functional recovery
CIN: cisplatin toxicity - i.p. cisplatin injection 7 mg/kg vs. placebo
EPO 100 U/kg i.p. after cisplatin, then daily for 9 days vs. placebo
↑functional recovery, ↑tubular regeneration, ↑DNA synthesis
CEPO: The administration of carbamylated EPO (CEPO), which does not bind to the classical EPOR, also provides renal tissue-protective effects. In an IR rat model, CEPO markedly reduced apoptosis and increased tubular epithelial cell proliferation. Moreover, CEPO was more protective against IR injury to tubular epithelial cells than EPO in this study. In an in vitro model performed by the same team, CEPO promoted more capillary formation than EPO and also appeared to protect the kidneys from IR injury by promotion of angiogenesis . This protective effect requires mitogenesis and endothelial progenitor cell differentiation, proliferation, and migration.
EPO activates endothelial nitric oxide synthase, and this effect on the endothelium may be critical for the renal tissue protective effects of EPO. EPO is an extremely potent stimulator of endothelial progenitor cells, whose function is partly dependent on nitric oxide bioavailability. Endothelial progenitor cells appear to be involved in endothelial recovery after injury. EPO limits AKI in part by stimulating vascular repair and by mobilizing endothelial progenitor cells and increasing tubular cell proliferation . These findings suggest that EPO may exert a protective effect via an interaction with the microvasculature.
Angiogenesis and EPO's renoprotective effects may be influenced by vascular endothelial growth factor (VEGF). Nakano and colleagues found that the vascular EPO/EPOR system promoted postischemic angiogenesis by upregulating the VEGF/VEGF receptor system, both directly by promoting neovascularization and indirectly by mobilising endothelial progenitor cells and bone marrow-derived proangiogenic cells . It appears that angiogenesis is impaired and blood vessels are less responsive to VEGF in the absence of EPOR.
EPO in AKI
AKI is common in critically ill patients [54, 55] and is independently associated with increased mortality, and with prolonged length of stay. It escalates both the human and financial costs of care. Therefore, it seems desirable to investigate treatments with potential to ameliorate or prevent AKI.
Some injury pathways for AKI in the critically ill include exposure to endogenous and exogenous toxins, metabolic factors, ischemia and reperfusion insults, neurohormonal activation, inflammation, and oxidative stress. Of these, ischemia-reperfusion may be the most common. EPO can prevent or reduce injury and assist renal repair and recovery through limitation of apoptosis, promotion of neovascularization, anti-inflammatory action, and tissue regeneration.
Investigation of potential treatments for AKI has had limited success to date; however, from the results of animal and some limited preliminary human studies, therapeutic use of EPO seems promising for those "at risk" for AKI.
Clinical trials of EPO in AKI
Comparison EPO in CABG surgery vs. EARLYARF trials
EPO in CABG
71 (EPO: 36, placebo: 35)
162 (EPO: 84, placebo: 78)
Aim: ICU patients at high risk of AKI; Obtained: critically ill patients
Prospective randomised double-blind, placebo-controlled trial
Prospective randomised double-blind placebo-controlled, trial
EPO type and dose
1 dose preop: 300 U/kg EPO or normal saline IV
2 doses: EPO-beta 500 U/kg to max 50,000 U or normal saline IV
> 18, elective CABG
↑ in GGT and ALP urine concentration product > 46.3
Emergent CABG, pre-existing AKI, on RRT, uncontrolled HT, nephrotoxic drugs within 3 days of op, previous use of EPO
< 16 yr, no IDC, hematuria, rhabdomyolysis, myoglobinuria, polycythemia, cytotoxic chemo, RRT or needs in 48 hr, stay ≤24 hr, survival ≤72 hr, prior RIFLE "failure"
Baseline SCr preop and 24, 72, and 120 hr postop
Baseline creatinine: various versions of preop/pre-ICU creatinine, including lowest on ICU admit/last ICU creatinine/minimum at 12 mo. Blood for creatinine and Cyst C and start for 4/24 creatinine clearance
Study groups: EPO vs. placebo
Baseline and intraoperative: no significant differences, most OPCABG (77%) (+3valves in EPO group)
EPO group older (p = 0.011) and ↑ likelihood for sepsis (p < 0.05). More placebo patients had AKI (not significant)
Incidence of AKI after CABG
A priori: Average % plasmaCr↑ from baseline over 4-7 days.
Changes in SCr and eGFR (first 5 days postop), ICU and hospital LOS, in-hospital mortality
AKIN & RIFLE AKI definitions, plasma cystatin C, need for dialysis, death within 7/30/90 days;
≥50%↑ in SCr from preop baseline
AKIN (creatinine and UO) and RIFLE (creatinine) definitions
EPO 8%, placebo 29%; p = 0.035
AKIN creatinine: EPO 45.2%, placebo 47.4%; RIFLE creatinine: EPO 23.8%, placebo 19.2%; AKIN UO: EPO 70.2%, placebo 51.3% (p = 0.016)
%SCr↑ at 24 hr: EPO 1 ± 3, placebo 15 ± 7 (p = 0.04). %SCr↑ at 120 hr: EPO 7 ± 4, placebo 27 ± 8 (p = 0.01). %eGFR↓ at 24 hr: EPO 3 ± 3, placebo -5 ± 4 (p = 0.04). %eGFR↓ at 120 hr: EPO -4 ± 3, placebo -13 ± 5 (p = 0.01)
No significant difference in 1° outcome or 2° outcomes except AKI (AKIN UO). Of randomised pts without AKI initially (n = 104) EPO patients had higher %plasmaCr↑: EPO 8.5 ± 27(n = 61), Placebo -4.6 ± 18 (n = 47; p = 0.004).
Onset of injury
Initiation of CABG operation
Heterogenous. Time of injury estimated for subdivision analysis. Samples from 6-12 hr after putative insult more predictive for AKI (AUC = 0.69), dialysis, and death.
CVS compromise, CPB exposure
No symptomatic thrombosis or other adverse events in EPO patients
No evidence for ↑intravascular thrombosis. EPO not associated with ↑ in adverse events.
A more recent and larger (n = 162) study (EARLYARF trial) assessed EPO's effect in ICU patients deemed at risk for AKI (defined by a specific cutoff value of two proximal tubular enzymes in urine: γ-glutamyl transpeptidase [GGT] and alkaline phosphatase [ALP]) (Table 3) . EPO was given at 500 U/kg IV when a high GGT × ALP product was detected and repeated 24 hours later. The primary outcome of this study was the average percent creatinine increase from baseline to its peak over 7 days. Unlike the study in CABG patients, this trial found no renoprotective effect of EPO. The reasons for these contradictory findings may be related to the differences in design and methods used.
The EARLYARF trial is the largest trial of EPO as a nephroprotective agent. However, it suffered from several important methodological limitations. First, it used poorly validated biomarkers as predictors of high risk for AKI. This approach, along with an untested cutoff value to trigger participant inclusion, resulted in the inclusion of a general critically ill cohort rather than only those at true high risk for AKI. The transient increase in urinary GGT and ALP seen in this trial, along with the uncertainty about the timing of the insult in a heterogeneous cohort, limited the ability to draw conclusions about the efficacy of early EPO administration. Importantly, the biomarkers selected to trigger protection against AKI by means of EPO therapy were very poor in predicting AKI with a receiver operating characteristic area under the curve of only 0.54. The decision to randomize was based solely on these biomarkers and did not take into account additional clinical factors that might assist in determining the risk of AKI.
A second problem in this study relates to the inclusion of patients with likely volume-responsive prerenal AKI, which would likely reduce the study's power, to determine the true efficacy of EPO. Fractional sodium excretion was low in most randomized patients, suggesting intact renal sodium reabsorption. The exclusion or identification and separate treatment of patients with prerenal AKI may reduce their confounding effect on results.
Third, serum creatinine measurements used for the baseline in the primary outcome were based on inconsistent criteria and timing. Some were taken before or around the time of ICU admission and others after adding additional confounders to the analysis. For the vast majority of patients, no creatinine measurement was available. Thus, the diagnosis of AKI was based on a retrospective (post-hoc) analysis using different criteria (lowest creatinine on ICU admission, last ICU value, lowest value at follow-up). These varying criteria can influence the accuracy of any assessment.
Fourth, at randomization, approximately one third of patients had already met the criteria for AKI, suggesting that the intervention was relatively late in the process of injury for many. In addition, the trial size was small with clear limitations in statistical power.
Fifth, in patients with early AKI (> 30%), measurement of the reduction in AKI stage and improved recovery should replace the use of development of AKI as an endpoint. RIFLE and AKIN classification systems can be used in this way.
Sixth, there were baseline differences between the study groups. For example, the EPO group were older and more likely to have sepsis (p < 0.05).
As discussed by the investigators, these limitations make it impossible to use this study to exclude a potential therapeutic renoprotective effect of EPO.
Potential risks of EPO
Pure red cell aplasia
Despite the numerous benefits of EPO, there are some risks. Pure red cell aplasia is a rare adverse event, which is characterized by anemia, low reticulocyte count, absence of erythroblasts, resistance to EPO, and neutralizing antibodies against EPO . This is an extremely rare complication.
EPO administration in patients with cancer has been associated with increased mortality and enhanced tumor growth . The underlying mechanisms remain uncertain, but patients with certain malignancies may be in a hypercoagulable state, making EPO administration unadvisable.
Recent studies and clinical trials have found an increased rate of thrombosis with EPO, which has mainly been observed in patient groups with higher than conventional levels of hemoglobin (> 120 g/L). Exclusion of patients with hemoglobin >120 g/L from clinical trials of EPO minimizes the risk for thrombosis. Nonetheless, systematic assessment for thrombosis should be performed in any EPO trials of critically ill patients because they have an increased risk for thrombosis.
Hypertension occurs in approximately 30% of patients who receive long-term EPO treatment and appears to involve increased endothelin release, upregulation of tissue renin and angiotensin production, changes in the balance of vasoactive substances (prostaglandin/prostacyclin/thromboxane), and an elevation of calcium by EPO (at least in chronic kidney disease) that impairs the vasodilating action of nitric oxide. It is advisable that patients with uncontrolled hypertension do not participate in trials of EPO in AKI.
Carbamylated EPO, a cytoprotective, nonerythropoietic derivative of EPO may not exhibit the same risks as EPO and holds great interest as a future tissue-protective therapy. However, it requires further experimental testing before it can be safely evaluated in clinical trials.
EPO-AKI and EPO-Biomarkers are the two components of the renal substudy of the EPO-TBI trial (NCT00987454). EPO-TBI is a trial of EPO as cerebral protection after traumatic brain injury, and the renal substudy assesses the effect of EPO on the development of acute kidney injury (AKI) and the response to treatment using multiple renal biomarkers with different time profiles in patients with traumatic brain injury. Having recently sustained a timed physical injury, this homogenous cohort lends itself to such a study. AKI will be classified using methods based on the RIFLE criteria. Baseline renal function will be taken from a consistent source for all patients. With a cohort of 606 patients, this will be the largest study of EPO to protect against AKI ever performed, increasing the probability of detecting a treatment effect. Furthermore, it will be the first EPO trial to incorporate active risk assessment for thrombotic episodes. Weekly intervals separate the doses of EPO (up to 3) in this trial to allow time for clearance and to avoid excessively high levels of EPO. In addition, patients with a known malignancy and/or uncontrolled hypertension will be excluded, thus minimizing risk to patients. In a paradoxical way, the EPO-TBI trial provides a unique opportunity to clarify the potential benefit of EPO as a kidney protective agent. This trial also may provide valuable insight into the mechanisms of EPO in AKI and pave the way for further dedicated large scale trials of EPO in AKI.
Many experimental studies and a strong biological rationale support the notion that EPO may be an effective nephroprotective drug. Only two studies have assessed its efficacy in this regard: one study of patients who received elective coronary artery bypass grafting, and the other in a heterogeneous group of critically ill patients. The first showed benefit; the second did not. Thus, there is uncertainty as to whether the experimental benefits can be translated into clinical benefits. A study of EPO in TBI, however, is now underway and will randomize 606 patients to placebo or EPO. This study will offer a unique opportunity to study, in a larger and more homogeneous cohort, whether EPO does confer renal protection in patients at risk of AKI. Until such data are available or other studies emerge to provide more clinical data, EPO remains an attractive but unproven nephroprotective agent.
We thank Dr. Alistair Nichol for his useful comments and advice.
- Mocini D, Leone T, Tubaro M, Santini M, Penco M: Structure, production and function of erythropoietin: implications for therapeutical use in Cardiovascular disease. Curr Med Chem 2007, 14: 2278–87. 10.2174/092986707781696627PubMedView ArticleGoogle Scholar
- Boissel JP, Lee WR, Presnell SR, Cohen FE, Bunn HF: Erythropoietin structure-function relationships. Mutant proteins that test a model of tertiary structure. J Biol Chem 1993, 268: 15983–93.PubMedGoogle Scholar
- Catlin DH, Breidbach A, Elliott S, Glaspy J: Comparison of the isoelectric focusing patterns of darbepoetin alfa, recombinant human erythropoietin, and endogenous erythropoietin from human urine. Clin Chem 2002, 48: 2057–9.PubMedGoogle Scholar
- Elliott S, Egrie J, Browne J, Lorenzini T, Busse L, Rogers N, et al.: Control of rHuEPO biological activity: the role of carbohydrate. Exp Hematol 2004, 32: 1146–55. 10.1016/j.exphem.2004.08.004PubMedView ArticleGoogle Scholar
- Rush RS, Derby PL, Smith DM, Merry C, Rogers G, Rohde MF, et al.: Microheterogeneity of erythropoietin carbohydrate structure. Anal Chem 1995, 67: 1442–52. 10.1021/ac00104a022PubMedView ArticleGoogle Scholar
- Rush RS, Derby PL, Strickland TW, Rohde MF: Peptide mapping and evaluation of glycopeptide microheterogeneity derived from endoproteinase digestion of erythropoietin by affinity high-performance capillary electrophoresis. Anal Chem 1993, 65: 1834–42. 10.1021/ac00062a007PubMedView ArticleGoogle Scholar
- Middleton SA, Barbone FP, Johnson DL, Thurmond RL, You Y, McMahon FJ, et al.: Shared and unique determinants of the erythropoietin (EPO) receptor are important for binding EPO and EPO mimetic peptide. J Biol Chem 1999, 274: 14163–9. 10.1074/jbc.274.20.14163PubMedView ArticleGoogle Scholar
- Weidemann A, Johnson RS: Nonrenal regulation of EPO synthesis. Kidney Int 2009, 75: 682–8. 10.1038/ki.2008.687PubMedView ArticleGoogle Scholar
- Jelkmann W: Erythropoietin after a century of research: younger than ever. Eur J Haematol 2007, 78: 183–205. 10.1111/j.1600-0609.2007.00818.xPubMedView ArticleGoogle Scholar
- Diskin CJ, Stokes TJ, Dansby LM, Radcliff L, Carter TB: Beyond anemia: the clinical impact of the physiologic effects of erythropoietin. Semin Dial 2008, 21: 447–54. 10.1111/j.1525-139X.2008.00443.xPubMedView ArticleGoogle Scholar
- Bahlmann FH, Fliser D: Erythropoietin and renoprotection. Curr Opin Nephrol Hypertens 2009, 18: 15–20. 10.1097/MNH.0b013e32831a9ddePubMedView ArticleGoogle Scholar
- Johnson DW, Forman C, Vesey DA: Novel renoprotective actions of erythropoietin: new uses for an old hormone. Nephrology 2006, 11: 306–12. 10.1111/j.1440-1797.2006.00585.xPubMedView ArticleGoogle Scholar
- Percy MJ, Lee FS, Percy MJ, Lee FS: Familial erythrocytosis: molecular links to red blood cell control. Haematologica 2008, 93: 963–7. 10.3324/haematol.13250PubMedView ArticleGoogle Scholar
- Li F, Chong ZZ, Maiese K: Erythropoietin on a tightrope: balancing neuronal and vascular protection between intrinsic and extrinsic pathways. Neurosignals 2004, 13: 265–89. 10.1159/000081963PubMedView ArticleGoogle Scholar
- Rusai K, Prokai A, Szebeni B, Fekete A, Treszl A, Vannay A, et al.: Role of serum and glucocorticoid-regulated kinase-1 in the protective effects of erythropoietin during renal ischemia/reperfusion injury. Biochem Pharmacol 2010, 79: 1173–81. 10.1016/j.bcp.2009.11.022PubMedView ArticleGoogle Scholar
- Myklebust JH, Smeland EB, Josefsen D, Sioud M: Protein kinase C-alpha isoform is involved in erythropoietin-induced erythroid differentiation of CD34(+) progenitor cells from human bone marrow. Blood 2000, 95: 510–8.PubMedGoogle Scholar
- Miller BA, Barber DL, Bell LL, Beattie BK, Zhang MY, Neel BG, et al.: Identification of the erythropoietin receptor domain required for calcium channel activation. J Biol Chem 1999, 274: 20465–72. 10.1074/jbc.274.29.20465PubMedView ArticleGoogle Scholar
- Figueroa YG, Chan AK, Ibrahim R, Tang Y, Burow ME, Alam J, et al.: NF-kappaB plays a key role in hypoxia-inducible factor-1-regulated erythropoietin gene expression. Exp Hematol 2002, 30: 1419–27. 10.1016/S0301-472X(02)00934-7PubMedView ArticleGoogle Scholar
- Yang CW, Li C, Jung JY, Shin SJ, Choi BS, Lim SW, et al.: Preconditioning with erythropoietin protects against subsequent ischemia-reperfusion injury in rat kidney. FASEB J 2003, 17: 1754–5. 10.1096/fj.02-0654revPubMedView ArticleGoogle Scholar
- Lui JC, Kong SK, Lui JC-K, Kong S-K: Heat shock protein 70 inhibits the nuclear import of apoptosis-inducing factor to avoid DNA fragmentation in TF-1 cells during erythropoiesis. FEBS Lett 2007, 581: 109–17. 10.1016/j.febslet.2006.11.082PubMedView ArticleGoogle Scholar
- Beere HM, Wolf BB, Cain K, Mosser DD, Mahboubi A, Kuwana T, et al.: Heat-shock protein 70 inhibits apoptosis by preventing recruitment of procaspase-9 to the Apaf-1 apoptosome. Nature Cell Biology 2000, 2: 469–75. 10.1038/35019501PubMedView ArticleGoogle Scholar
- Elliott S, Pham E, Macdougall IC, Elliott S, Pham E, Macdougall IC: Erythropoietins: a common mechanism of action. Exp Hematol 2008, 36: 1573–84. 10.1016/j.exphem.2008.08.003PubMedView ArticleGoogle Scholar
- Salahudeen AK, Haider N, Jenkins J, Joshi M, Patel H, Huang H, et al.: Antiapoptotic properties of erythropoiesis-stimulating proteins in models of cisplatin-induced acute kidney injury. Am J Physiol Renal Physiol 2008, 294: F1354–65. 10.1152/ajprenal.00131.2008PubMedView ArticleGoogle Scholar
- Silva M, Benito A, Sanz C, Prosper F, Ekhterae D, Nunez G, et al.: Erythropoietin can induce the expression of bcl-x(L) through Stat5 in erythropoietin-dependent progenitor cell lines. J Biol Chem 1999, 274: 22165–9. 10.1074/jbc.274.32.22165PubMedView ArticleGoogle Scholar
- Chatterjee PK: Novel pharmacological approaches to the treatment of renal ischemia-reperfusion injury: a comprehensive review. Naunyn Schmiedebergs Arch Pharmacol 2007, 376: 1–43. 10.1007/s00210-007-0183-5PubMedView ArticleGoogle Scholar
- Joyeux-Faure M, Godin-Ribuot D, Ribuot C: Erythropoietin and myocardial protection: what's new? Fundam Clin Pharmacol 2005, 19: 439–46. 10.1111/j.1472-8206.2005.00347.xPubMedView ArticleGoogle Scholar
- Westenfelder C, Biddle DL, Baranowski RL: Human, rat, and mouse kidney cells express functional erythropoietin receptors. Kidney Int 1999, 55: 808–20. 10.1046/j.1523-1755.1999.055003808.xPubMedView ArticleGoogle Scholar
- Ates E, Yalcin AU, Yilmaz S, Koken T, Tokyol C, Ates E, et al.: Protective effect of erythropoietin on renal ischemia and reperfusion injury. ANZ J Surg 2005, 75: 1100–5. 10.1111/j.1445-2197.2005.03612.xPubMedView ArticleGoogle Scholar
- Esposito C, Pertile E, Grosjean F, Castoldi F, Diliberto R, Serpieri N, et al.: The improvement of ischemia/reperfusion injury by erythropoietin is not mediated through bone marrow cell recruitment in rats. Transplant Proc 2009, 41: 1113–5. 10.1016/j.transproceed.2009.03.008PubMedView ArticleGoogle Scholar
- Forman CJ, Johnson DW, Nicol DL: Erythropoietin administration protects against functional impairment and cell death after ischaemic renal injury in pigs. BJU Int 2007, 99: 162–5. 10.1111/j.1464-410X.2006.06505.xPubMedView ArticleGoogle Scholar
- Gong H, Wang W, Kwon T-H, Jonassen T, Li C, Ring T, et al.: EPO and alpha-MSH prevent ischemia/reperfusion-induced down-regulation of AQPs and sodium transporters in rat kidney. Kidney Int 2004, 66: 683–95. 10.1111/j.1523-1755.2004.00791.xPubMedView ArticleGoogle Scholar
- Imamura R, Moriyama T, Isaka Y, Namba Y, Ichimaru N, Takahara S, et al.: Erythropoietin protects the kidneys against ischemia reperfusion injury by activating hypoxia inducible factor-1alpha. Transplantation 2007, 83: 1371–9. 10.1097/01.tp.0000264200.38926.70PubMedView ArticleGoogle Scholar
- Imamura R, Okumi M, Isaka Y, Ichimaru N, Moriyama T, Imai E, et al.: Carbamylated erythropoietin improves angiogenesis and protects the kidneys from ischemia-reperfusion injury. Cell Transplant 2008, 17: 135–41. 10.3727/000000008783907044PubMedView ArticleGoogle Scholar
- Johnson DW, Pat B, Vesey DA, Guan Z, Endre Z, Gobe GC: Delayed administration of darbepoetin or erythropoietin protects against ischemic acute renal injury and failure. Kidney Int 2006, 69: 1806–13. 10.1038/sj.ki.5000356PubMedView ArticleGoogle Scholar
- Kiris I, Kapan S, Kilbas A, Yilmaz N, Altuntas I, Karahan N, et al.: The protective effect of erythropoietin on renal injury induced by abdominal aortic-ischemia-reperfusion in rats. J Surg Res 2008, 149: 206–13. 10.1016/j.jss.2007.12.752PubMedView ArticleGoogle Scholar
- Nemoto T, Yokota N, Keane WF, Rabb H: Recombinant erythropoietin rapidly treats anemia in ischemic acute renal failure. Kidney Int 2001, 59: 246–51. 10.1046/j.1523-1755.2001.00485.xPubMedView ArticleGoogle Scholar
- Patel NSA, Sharples EJ, Cuzzocrea S, Chatterjee PK, Britti D, Yaqoob MM, et al.: Pretreatment with EPO reduces the injury and dysfunction caused by ischemia/reperfusion in the mouse kidney in vivo. Kidney Int 2004, 66: 983–9. 10.1111/j.1523-1755.2004.00847.xPubMedView ArticleGoogle Scholar
- Phillips CK, Hruby GW, Mirabile G, Motamedinia P, Lehman DS, Okhunov Z, et al.: Erythropoietin-induced optimization of renal function after warm ischemia. J Endourol 2009, 23: 359–65. 10.1089/end.2008.0183PubMedView ArticleGoogle Scholar
- Sharples EJ, Patel N, Brown P, Stewart K, Mota-Philipe H, Sheaff M, et al.: Erythropoietin protects the kidney against the injury and dysfunction caused by ischemia-reperfusion. J Am Soc Nephrol 2004, 15: 2115–24. 10.1097/01.ASN.0000135059.67385.5DPubMedView ArticleGoogle Scholar
- Spandou E, Tsouchnikas I, Karkavelas G, Dounousi E, Simeonidou C, Guiba-Tziampiri O, et al.: Erythropoietin attenuates renal injury in experimental acute renal failure ischaemic/reperfusion model. Nephrol Dial Transplant 2006, 21: 330–6. 10.1093/ndt/gfi177PubMedView ArticleGoogle Scholar
- Vesey DA, Cheung C, Pat B, Endre Z, Gobe G, Johnson DW: Erythropoietin protects against ischaemic acute renal injury. Nephrol Dial Transplant 2004, 19: 348–55. 10.1093/ndt/gfg547PubMedView ArticleGoogle Scholar
- Abdelrahman M, Sharples EJ, McDonald MC, Collin M, Patel NSA, Yaqoob MM, et al.: Erythropoietin attenuates the tissue injury associated with hemorrhagic shock and myocardial ischemia. Shock 2004, 22: 63–9. 10.1097/01.shk.00001276869.21260.9dPubMedView ArticleGoogle Scholar
- Andreucci M, Fuiano G, Presta P, Lucisano G, Leone F, Fuiano L, et al.: Downregulation of cell survival signalling pathways and increased cell damage in hydrogen peroxide-treated human renal proximal tubular cells by alpha-erythropoietin. Cell Prolif 2009, 42: 554–61. 10.1111/j.1365-2184.2009.00617.xPubMedView ArticleGoogle Scholar
- Bagnis C, Beaufils H, Jacquiaud C, Adabra Y, Jouanneau C, Le Nahour G, et al.: Erythropoietin enhances recovery after cisplatin-induced acute renal failure in the rat. Nephrol Dial Transplant 2001, 16: 932–8. 10.1093/ndt/16.5.932PubMedView ArticleGoogle Scholar
- Bi B, Guo J, Marlier A, Lin SR, Cantley LG: Erythropoietin expands a stromal cell population that can mediate renoprotection. Am J Physiol Renal Physiol 2008, 295: F1017–22. 10.1152/ajprenal.90218.2008PubMed CentralPubMedView ArticleGoogle Scholar
- Fishbane S, Ragolia L, Palaia T, Johnson B, Elzein H, Maesaka JK, et al.: Cytoprotection by darbepoetin/epoetin alfa in pig tubular and mouse mesangial cells. Kidney Int 2004, 65: 452–8. 10.1111/j.1523-1755.2004.00400.xPubMedView ArticleGoogle Scholar
- Goldfarb M, Rosenberger C, Ahuva S, Rosen S, Heyman SN: A role for erythropoietin in the attenuation of radiocontrast-induced acute renal failure in rats. Ren Fail 2006, 28: 345–50. 10.1080/08860220600591420PubMedView ArticleGoogle Scholar
- Hamano Y, Aoki T, Shirai R, Hatano M, Kimura R, Ogawa M, et al.: Low-dose darbepoetin alpha attenuates progression of a mouse model of aristolochic acid nephropathy through early tubular protection. Nephron Experimental Nephrology 2010, 114: e69–81. 10.1159/000256569PubMedView ArticleGoogle Scholar
- Kang D-H, Park E-Y, Yu ES, Lee Y-S, Yoon K-I: Renoprotective effect of erythropoietin (EPO): possibly via an amelioration of renal hypoxia with stimulation of angiogenesis in the kidney. Kidney Int 2005, 67: 1683. 10.1111/j.1523-1755.2005.00264.xPubMedView ArticleGoogle Scholar
- Mitra A, Bansal S, Wang W, Falk S, Zolty E, Schrier RW: Erythropoietin ameliorates renal dysfunction during endotoxemia. Nephrol Dial Transplant 2007, 22: 2349–53. 10.1093/ndt/gfm216PubMedView ArticleGoogle Scholar
- Nijboer WN, Ottens PJ, van Dijk A, van Goor H, Ploeg RJ, Leuvenink HGD: Donor pretreatment with carbamylated erythropoietin in a brain death model reduces inflammation more effectively than erythropoietin while preserving renal function. Crit Care Med 2010, 38: 1155–61. 10.1097/CCM.0b013e3181cf6e78PubMedView ArticleGoogle Scholar
- Vaziri ND, Zhou XJ, Liao SY: Erythropoietin enhances recovery from cisplatin-induced acute renal failure. Am J Physiol 1994, 266: F360–6.PubMedGoogle Scholar
- Nakano M, Satoh K, Fukumoto Y, Ito Y, Kagaya Y, Ishii N, et al.: Important role of erythropoietin receptor to promote VEGF expression and angiogenesis in peripheral ischemia in mice. Circ Res 2007, 100: 662–669. 10.1161/01.RES.0000260179.43672.fePubMedView ArticleGoogle Scholar
- Bagshaw SM, George C, Dinu I, Bellomo R: A multi-centre evaluation of the RIFLE criteria for early acute kidney injury in critically ill patients. Nephrol Dial Transplant 2008, 23: 1203–10. 10.1093/ndt/gfm744PubMedView ArticleGoogle Scholar
- Ostermann M, Chang RWS: Acute kidney injury in the intensive care unit according to RIFLE. Crit Care Med 2007, 35: 1837–43. 10.1097/01.CCM.0000277041.13090.0APubMedView ArticleGoogle Scholar
- Song YR, Lee T, You SJ, Chin HJ, Chae D-W, Lim C, et al.: Prevention of acute kidney injury by erythropoietin in patients undergoing coronary artery bypass grafting: a pilot study. Am J Nephrol 2009, 30: 253–60. 10.1159/000223229PubMedView ArticleGoogle Scholar
- Endre ZH, Walker RJ, Pickering JW, Shaw GM, Frampton CM, Henderson SJ, et al.: Early intervention with erythropoietin does not affect the outcome of acute kidney injury (the EARLYARF trial). Kidney Int 2010, 77: 1020–30. 10.1038/ki.2010.25PubMedView ArticleGoogle Scholar
- McKoy JM, Stonecash RE, Cournoyer D, Rossert J, Nissenson AR, Raisch DW, et al.: Epoetin-associated pure red cell aplasia: past, present, and future considerations. Transfusion 2008, 48: 1754–62. 10.1111/j.1537-2995.2008.01749.xPubMed CentralPubMedView ArticleGoogle Scholar
- Bohlius J, Schmidlin K, Brillant C, Schwarzer G, Trelle S, Seidenfeld J, et al.: Recombinant human erythropoiesis-stimulating agents and mortality in patients with cancer: a meta-analysis of randomised trials. Lancet 2009, 373: 1532–42. 10.1016/S0140-6736(09)60502-XPubMedView ArticleGoogle Scholar
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